Gabriel Steg – Hello. Gilles Pialoux. I am delighted to meet you on Medscape France at the beginning of August to give a brief update on monkeypox, as an infectiologist at Sorbonne University and also at the Tenon hospital in Paris, where we see about 10 to 12 cases per day and that we vaccinate 20 to 40 people, therefore an indisputable reality for a very intriguing emerging phenomenon.
First, some epidemiological data. The latest French public health data from the end of July show 1,955 cases, 96% in men who have sex with men – MSM – for an average age of around 36 years. We have around 18,000 cases worldwide, including 70% of cases in Europe – 4,900 cases in Spain with two deaths which are, for the moment, under investigation and for which we would like to have the real causes. of these deaths in young patients
So, we had a few posts and a few questions. On the publications, we can refer to a very nice clinical article of the New England Journal of Medicine dated July 23, where a European team, 16 countries, reports the clinical manifestations and sociodemographic data of 528 patients. Obviously, we find confirmation of a dominance of MSM, gay and bisexual men – 98%. Probably a magnifying effect, since 41% of these cases, in this series of New England are HIV-infected patients, so probably a magnifying effect by the arrival of patients who are followed either for HIV, or for PrEP, for pre-exposure prophylaxis.
Second confirmation of the field in this paper from New England, is the diversity of clinical manifestations — totally different from what we were offered in the epidemics observed in West and Central Africa, and also in the United States, in 2003. So, with manifestations general: fever in 62% of cases, lethargy, neurological signs, headaches, significant lymphadenopathy, and not just pelvic. And then extremely varied mucosal and cutaneous manifestations with, in particular, an extremely confusing exanthema on the diagnostic level, which will require doctors to be trained in undressing patients, who have simple exanthema, which is a fairly frequent dermatological manifestation. And then very varied ENT manifestations.
Confirmation, too, of the presence of the virus almost everywhere and in all fluids, whether in semen, in blood — we even found some, in Tenon, in pleural fluid or bronchoalveolar lavage — so a virus that spreads extremely heavily. And a confirmation too, therefore, a diagnosis which is made by PCR quite easily, the absence of deaths, apart from the Spanish deaths in this series of New Englandand the deaths were after publication, and the very low access to treatment, since less than 3% of patients had access, in particular, to an antiviral called técovirimat.
The issue of doses
So that’s the clinical setting. There is another question that is of concern to us at the moment, and that is the question of doses. And we come back to a debate on COVID-19, since you know that the recommendations refer to two doses, except in immunocompromised subjects for whom 3 vaccine doses of third generation vaccine are recommended. But there is a vagueness where the defense secret is mixed up – since, as you know, the number of doses is a defense secret – and then the recommendations of the high health authority, which say that the second injection must be done at least at 28 days, which leaves an upper limit of time, so we don’t know if it’s one month, two months, three months, four months, so there is a real problem.
And we, in the field, we also have the problem of vaccinating immunocompromised people, especially HIV patients. And, there, we took up the literature a little bit. And, so, there are several trials: there are randomized trials that were published by Overton in 2020 in Vaccinated which is extremely well done and which shows the interest of the boost by a third dose in HIV patients who are somewhat immunocompromised – around 370 CD4, we had another older study, published in the Journal of Infectious Diseases of 2013, by Greenberg, which also showed the good immune response in HIV patients, but for the moment we are in the dark, and at the French Society for the Fight against AIDS, we are thinking about the recommendations that we have to do.
Two other feedbacks on older publications: a very well done paper, prior, of course, to this re-emergence of monkeypox on the question of the void left by the disappearance, the eradication of smallpox, and there is a question there particularly in terms of bioterrorism, since you know that this is one of the obsessions of our rulers and that smallpox — so, this this time it’s not monkeypox, smallpox, the real one, the real smallpox, so to speak, is classified as level 1 by the CDC and then by all the European countries in agents of bioterrorism , and that infinitely complicates recommendations in the field.
And there is a very nice review published in Viruses on this risk of bioterrorism, knowing that mortality with smallpox was around 30% – the question of mortality for monkeypox, for the monkeypox, is more complicated, since the data from African publications ranged from 0% to 10% and that, for the moment, indeed, apart from the two cases mentioned above, we are in an extremely low mortality, even close to zero.
And, finally, one last point: I think that, like many, we will return to the articles that were published during the re-emergence, particularly in the United States, of monkeypox on the concept of One Healththat is to say of a management of these zoonoses not only from the medical aspect, but from the environmental aspect and also from the veterinary medicine aspect, and that this concept of OneHealth, born in the 2000s, is obviously going to be, in the wake of COVID, extremely important in understanding what to do for these re-emergences of zoonoses. Thank you.
Thank you and see you soon on Medscape.
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